MRI Form

Patient Information

Patient First Name

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Patient Last Name

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Phone Number

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Patient Date of Birth

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Referring Physician

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Physician's Practice

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Do you have a prescription for your MRI?

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Area of the body for MRI to be performed:

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Have you had prior treatment for this injury?

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Date of Injury

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If you are a female patient, are you pregnant?

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If you are a female patient, are you currently breastfeeding?

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Do you have implanted medical devices or metal anywhere in your body?

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Have you ever been injured to the eye involving a metallic foreign body, silvers or shavings?

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Have you ever been injured by a bullet, BB or shrapnel?

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Do you wear medication patches and/or diabetic monitoring devices?

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Insurance Information

We do not accept Aetna Better Health, Aetna Washington Prime HMO, Amerihealth Caritas (only covers if listed as a secondary insurance), Gateway Medicaid, Keystone First, Highmark Together Blue EPO, Humana Medicare, Highmark Whole Care, UPMC for You, UPMC EPO, UPMC PPO (only accepted if out of network coverage available).

Insurance Name

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Type of Insurance

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Group Number

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Member ID Number

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Authorization Number

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Scheduling Information

Preferred Day of the Week

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Preferred Time of Day

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Do you wish to be put on a cancellation list?

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What is the best phone number we can use to contact you for scheduling?

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Today's Date

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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